Essential to the beauty of dance are the demanding biomechanics of the dancer, particularly at the foot and ankle. Injuries and pain are almost inevitable. But an understanding of the underlying issues—artistic as well as anatomical—can help practitioners keep dancers on their toes for as long as possible.
By Jeffrey A. Russell, PhD, ATC
Several authors have identified the intense, athletic, physical performance nature of dance,1-5 which is in contrast to its obvious categorization as an artistic endeavor. Given the expansive injury panorama seen in dancers,6-10 the atypical way dancers process pain,11-14 and the problems encountered in communication between dancers and healthcare professionals,15,16 there is a need for clinicians and researchers to understand dance injuries and to engage more effectively with dancers, not only to better care for these specialized athletes but to disseminate knowledge about dance injuries across the healthcare profession.
Dance medicine and science is receiving increasing attention through the excellent efforts of organizations such as the International Association for Dance Medicine and Science (www.iadms.org) and its two publications, the Journal of Dance Medicine and Science and the Bulletin for Teachers. A number of other organizations worldwide offer equally valuable attention to this field.17 Lower extremity practitioners who treat dancers will benefit from an understanding of the importance of the ankle and foot in dance, specifically the extreme motion in the ankle and foot required of ballet dancers, as well as the relevant anatomical features related to dance injuries.
Ankle and foot motion required in ballet
Few, if any, physical activities besides ballet require an individual to move between forced maximum weightbearing dorsiflexion (a position called demi-plié) and forced maximum weightbearing plantar flexion (the en pointe position); these are shown in Figures 1 and 2. Both these maneuvers put tremendous strain on the ankles and feet because the bones are loaded in weightbearing and the soft tissues must tether the bones sufficiently to control their positions and minimize the occurrence of injury.
For example, when en pointe, the posterior edges of the tibial plafond, the posterior talus, and the superior calcaneus converge to the point of impact in virtually every dancer.14,18 Other genres of dance, while not necessarily dependent on the maximum ankle range of motion seen in ballet, nonetheless place their own rigorous physical demands on the ankles and feet. Unfortunately, to date they have not gained the attention of researchers to the same extent as ballet.
Assessment of ankle range of motion
From a clinical perspective in physical examination and injury rehabilitation, effective assessment of a dancer’s ankle range of motion is important. Interestingly, ballet dancers’ dorsiflexion tends to decrease with increasing dance experience and proficiency.19,20 The heavy emphasis dancers place on plantar flexion20 and bone blocks created when anterior exostoses emanate from repeated impingement of the anterior edge of the tibial plafond against the dorsal sulcus of the talus during demi-plié 21-23 may account for this general finding. However, maximum dorsiflexion in dancers is often not substantially different from that seen in nondancers and, thus, dorsiflexion in dancers can be assessed satisfactorily with a goniometry technique that is essentially equivalent to that described for the general population.24-26
On the other hand, plantar flexion assessment in ballet dancers presents a unique challenge. In the extreme position of a dancer’s maximum plantar flexion, a sizeable percentage of the motion required to attain this position is contributed by the foot bones,27 but attaining the amount of plantar flexion seen commonly in ballet dancers suggests that the dancers also must exhibit substantially greater talocrural motion than is typical.27
Motion of the foot bones contributes to overall plantar flexion in nondancers as well28,29 but, because the total amount of motion possible in the ankle-foot complex is so large in dancers, the customary method of goniometry may not be suitable for determining their plantar flexion.19,30 This has to do with difficulty in locating appropriate placements of the goniometer’s axis and distal arm with the foot in plantar flexion that approaches, and may even surpass, 90° in highly trained ballet dancers.30 (The largest plantar flexion range of motion in dancers reported in the scientific literature was in a group of New York City professional female ballet dancers: a mean of 113°.20) That is, the ankle having a mobile axis of rotation rather than being a true single axis hinge joint31,32 and the movement of the foot bones, particularly the intended goniometric landmark of the fifth metatarsal,27 complicate the procedure.
In short, the question of whether goniometry is a suitable technique in such cases seems justifiable, particularly since the reported plantar flexion norm for the general population using this method is only 50°.24,25,33,34 Inclinometry has been suggested as a viable alternative.19,35
Foot and ankle injuries in dancers
Properly functioning ankles and feet are crucial to success in dance. They form the connection between the artist and the floor, and—less obvious perhaps to those unaccustomed to watching dancers perform—the intricacies of ankle and foot movements and positioning are woven into the aesthetic of any given dance movement. The anatomical focus herein will be on factors that specifically relate to clinical care of dancers.
The ankle is frequently injured in dance, accounting for up to 31% of dancers’ reported injuries.36-42 When foot injuries are included, the combined total accounts for up to 57% of all dance injuries.7,37,40-43 Overuse injuries tend to be more common than traumatic injuries;6,40,44 this is likely due to the repetitive nature of dance training coupled with the inability of the body’s tissues to withstand the demands imposed on them. In the ankle region, lateral sprains are the most common traumatic injury across all sports,45 including dance.40 Achilles tendinopathy and flexor hallucis longus tendinopathy (“dancer’s tendinopathy”) are frequently encountered overuse conditions. In the foot, spiral fracture of the fifth metatarsal shaft (“dancer’s fracture”) and bifurcate ligament sprain are two common traumatic injuries, while metatarsal stress fractures, Morton’s neuroma, and plantar fasciitis fall into the overuse category.
The prevalence of lateral ankle sprain and dancer’s fracture may be explained at least partially by the fact that dancers spend so much time performing relevé (essentially a heel raise). Figure 3 shows the relevé position with the at-risk anterior talofibular ligament and fifth metatarsal subject to injurious forces if the dancer falls into inversion from a plantar flexed stance. However, counterintuitively, this mechanism is less likely when the ankle is in maximal plantar flexion,46 such as when a dancer stands in demi-pointe (raising as high on the metatarsal heads as possible with the toes hyperextended), or en pointe, because convergence of the posterior edge of the tibial plafond, the posterior talus, and the superior calcaneus stabilize the talocrural joint.8, 47
The Achilles tendon’s location posterior to the ankle exposes it to undue forces especially when a dancer is en pointe. Wrapping a pair of satin shoe ribbons around each ankle is a fundamental practice of a pointe dancer; more than a cosmetic piece of the ballet dancer’s wardrobe, they encircle the distal leg and ankle snugly to help provide stability to the ankle and foot.
Variable compression of tendon fibers—for example, when the ribbons bind the posterior aspect of the Achilles tendon or the pointe shoe’s posterior heel counter impels the tendinous insertion—is one suspected contributor to tendinopathy.48,49 Furthermore, when a dancer is en pointe, the requisite maximum plantar flexion positions the tendon in a curved orientation that allows the overlying folds of skin and subcutaneous tissue and the shoe ribbons to apply a fulcrum against it17 (Figure 4).
Bony impingement injuries
If anatomical variants such as an extended lateral talar tubercle (Stieda’s process) or an os trigonum are present when the extreme plantar flexion required in dance is attempted, range of motion may be limited and a dancer may report symptoms of posterior ankle impingement syndrome.9,18,50-52 Os trigonum, sometimes demonstratively labeled “nutcracker syndrome,”53,54 is an accessory bone that sits posterior to the talus; this is depicted in Figure 5. This ossicle is usually present as a portion of the lateral talar tubercle that does not unite during skeletal maturation.55,56
It has been theorized that trauma during the ossification stage can disrupt the apophyseal closure,55,56 thus leading to the os trigonum. Certainly this is a reasonable mechanism in dancers, considering their emphasis on maximal plantar flexion, especially as they typically begin pointe work at the age when the tubercle is ossifying. Often dancers are able to participate at a very high, professional level with an asymptomatic os trigonum57 even though they may exhibit a higher prevalence of this variant than the nondancer population.18 In addition, research suggests that a prominent superior calcaneal tubercle and a downward protruding posterior edge of the tibial plafond predispose dancers to posterior impingement symptoms.18 Overall, the repetitive plantar flexion requirements of dance, particularly ballet, logically suggest that dancers will be more likely than nondancers to encounter difficulties with posterior ankle impingement syndrome.
As previously noted, forced weightbearing dorsiflexion such as the demi-pliés routinely performed in dance training can cause exostoses to develop on the anterior edge of the tibial plafond, the dorsal neck of the talus, or both as the tibia and talus repetitively contact one another. Nondancers do not typically exhibit these outgrowths because it is rare for them to dorsiflex in weightbearing to the depth required of dancers and because the dorsal sulcus on the talar neck normally receives the tibia without impact.22 When a dancer experiences bony anterior impingement to the point of exostosis formation, the demi-plié likely will be painful and limited in range. When severe enough, surgery will relieve the symptoms; however, continued dance training usually stimulates return of the exostoses and dancers’ symptoms.22
Special clinical considerations
Providing healthcare to dancers is exceptionally gratifying when approached with genuine interest and a desire to learn as much as possible about these gifted athletic artists. Such care also can be exceptionally challenging. With respect to the ankle and foot, several caveats illuminate some stark differences between dance medicine and typical sports medicine.
Dancers approach both pain threshold and pain tolerance differently than nondancers,12 and they may not discern well between types of pain.11 They tend to be fastidious and present an outward appearance of being in control, even under very difficult circumstances. Yet, when well-cared for, their gratitude is particularly expressive. Engaged in what they often view as a seemingly continual battle to gain respect for the high levels of physicality and intensity involved in executing their art form, dancers respond favorably to clinicians who are helpful.
Unfortunately, most dancers offer anecdote after frustrating anecdote about traditional healthcare providers who deliver only a single treatment option: “Stop dancing.” Certainly discontinuation of injurious activity is warranted in some instances; but dancers often report a disinterest by their healthcare providers in finding ways to balance a modified continuation of dancing with treatment to ameliorate symptoms and return to full activity. Practitioners caring for dancers are best equipped by spending time learning about dance and dancers, and patients will respond when clinicians take the time to deliberately listen to the clinical histories dancers provide. Unquestionably, good communication is essential to the best dance medicine care.15
An actual case of a 14-year-old, highly talented, preprofessional ballerina may serve to illustrate this point. The young dancer approached a dance medicine practitioner for advice following several months of general physical therapy for a great toe injury her previous provider termed “turf toe” (i.e., a sprained first metatarsophalangeal joint). No amount or type of treatment or rehabilitation had proven helpful; relative rest seemed beneficial, but did not yield complete resolution. Both the dancer and her mother were, as is typical in such situations with dancers, exasperated with the healthcare system; this led to their decision to seek dance medicine-specific care.
A detailed history and exam by the dance medicine clinician revealed that the pain was not actually manifest in the metatarsophalangeal joint, but underneath and slightly proximal to it. Another important finding was that the pain was particularly severe when the dancer stood on demi-pointe (essentially on the balls of the foot) in her pointe shoes, which have a hard inner sole under the forefoot. Therefore, the clinician settled on the differential impressions of first metatarsal sesamoiditis, bipartite sesamoid, and fractured sesamoid. Subsequent X-rays and magnetic resosnace imaging studies revealed a bipartite lateral sesamoid with an inflamed fibrous union.
A course of complete rest from dance was instituted, with small “tests” of healing progress from time to time. Following a full year of recuperation, the dancer returned to her previous level of preprofessional conservatory training. Three general points are underscored by this case: 1) the lack of “dancer-friendly” healthcare is very disconcerting to dancers; 2) correct injury evaluation and treatment are paramount to efficient and efficacious care; and 3) sometimes seemingly minor conditions can be debilitating to highly trained athlete-performers.
Unlike traditional sports, in which personal equipment for injury protection and restoration are well entrenched and a wide variety of healthcare specialists such as team physicians and athletic trainers attend to virtually every medical need of athletes, dance historically has not enjoyed such opportunities. Thus dancers’ approaches to typical sports medicine practices are filled with hesitation, objections, or both. Wardrobe constraints may preclude utilizing, for example, supportive braces and extensive taping, which cannot be hidden by socks and sneakers, or under uniforms. Furthermore, these devices do not have the benefit of acceptance in an artistic performance venue the way they do in a sports arena.
In the ankle, bracing and taping unacceptably limit the important plantar flexion required for dance aesthetics and technical proficiency; thus, they often are discarded as options. Foot orthotics can be variably applied across genres of dance. D-shaped navicular lift or longitudinal arch pads are useful in many types of dance footwear for dancers with pes planus or pronation. Conversely, pointe shoes fit so closely to the foot that few, if any, foot support or injury care products are suitable or tolerated. Even if such devices could be incorporated, dancers’ need for the shoes to fit perfectly and the need for their feet to feel the floor render most attempts difficult at best.
Modern dance, marked by its bare feet, offers no shoes at all in which to place orthotic devices, and affixing anything to the feet disrupts the quality of the foot-floor interface. These types of challenges require emphasis on preventive and rehabilitative modalities such as exercise and manual therapies, along with a minimalist approach to taping support. Parenthetically, while it may be tempting to equate the demands on barefoot modern or contemporary dancers with those of barefoot runners, the characteristics of the physical activities of these two groups are completely different.
Dancers are a special type of athlete whose art form is physically rigorous. They possess extraordinary physical attributes and abilities; the feet and ankles comprise just one region of the body where this is true. These attributes and abilities, combined with an intriguing psyche, present challenges in clinical care. However, healthcare practitioners motivated to invest time and energy in genuinely caring for dancers will find a group of gracious and thankful patients.
Jeffrey A. Russell, PhD, ATC, is an assistant professor of dance science and director of the Laboratory for Science and Health in Artistic Performance in the Department of Dance at the University of California, Irvine.
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